Which is confusing, as we have had an experiment going for the past six months or so, where we are not admitting our practice’s patients when they are admitted to our hospital; rather, we are using the residents’ service or the hospitalist service to handle their hospitalization, and we are encouraged to only stop in for a social visit, and if necessary, to communicate with the inpatient team.
A venerable older physician had once told me, in no uncertain terms, that a doctor who does not admit patients and take care of patients in the hospital is not a real doctor. I quote, “If you don’t admit and follow your own patients in the hospital, you might as well have just been a nurse practitioner.”
(As a side note, I have wondered why I didn’t become a nurse practitioner, for other reasons: an N.P. degree, while a difficult undertaking and an expensive investment, would have required significantly less time and much less money than the convoluted M.D. pathway I ended up choosing. Maybe I wouldn’t still owe my alma mater over a hundred thousand dollars if I’d just gotten the N.P and gotten a job… Oh well, here I am.)
And I do take issue with the “just”. No one’s just an N.P., just like no one’s just a respiratory therapist or just an EMT. All these different roles are just as essential to the care of the patient as the doctor, right? Well, yes, but, I was, at the heart of it, scared of this implication, of being just an outpatient doctor… insecure about my own skills and talents, and thus extremely resistant to “letting go” of inpatient care, for a long, long time.
And now, we’re not doing inpatient care.
Or aren’t we?
In the past few months, the way I follow my patients in-hospital has not ceased, but rather, changed. Before this experiment, a week of being “on-call” meant taking all the weekend patient phone calls (and weekday phone calls for the doctors who were away), AND admitting/ rounding on/ discharging inpatients, while seeing as many of my own outpatients as I thought I could manage. For me, I would block off a whole week of morning clinics, plan to be at the hospital late every day, and plan to spend all weekend in the hospital, requiring extra help for the kids, and I’d feel totally stressed out.
Then, when I wasn’t on-call, if one of my patients was admitted, I’d just ask the on-call doctor to see them for me, even asking them to check in on the care of a patient on the surgical service, or do a “social” visit, courtesy of our practice. If I wasn’t on-call, I wasn’t on the floors, with few exceptions.
Now… Since we don’t have to admit/ round/ discharge, my weeks on call are more like a regular week, with a few more phone calls. There has been no weekend time in the hospital.
So, for the past few months, whether I am on-call or not, I try to just stop in and see my own patients when they are admitted. Not to admit them, but just, to see them. I can’t always do this, but generally, I’ve been able to catch people in the emergency room or up on the floors, and chat a bit, sometimes explain a test result, sometimes to chat with the resident or hospitalist team, make sure we’re all on the same page… and sometimes a whole lot more.
Like the hourlong goals-of-care meeting I had with the the huge cantankerous family of an elderly quite sick patient… Or the multiple emails and tracking down of all of the specialists for another very complicated patient, to make sure everyone was on the same page about an issue.
I’ve found that with these and with some other cases, it made so, so, so much more sense for me to be taking the extra time and effort, rather than give it all to the person in my practice who was on-call. It’s saved time, in a way, as I then knew more about their hospital stay when they were discharged. SO much easier than trying to read someone’s discharge summary for all the details. And, patients and families have been so, so grateful, which is in itself so fulfilling.
Now, there’s pros and cons to NOT being in charge of all of the admission, of all the details and ordering a team about. The pro is, it’s alot, alot, alot less time and hassle. The con is, if I see something that I think should be done, like a lab checked or a study ordered, I have to page or hunt down the person writing the orders, and then be political about it. Most often, this is fine. Sometimes, this is a feat. Also, as I’m not officially in charge during these admissions, I can’t bill for alot of this extra work. The max is a 30$ reimbursement for one “continuity” visit with my patient, per week of their admission. (That as compared with about $200 for an admission, maybe $45 for each hospital day visit and maybe $150 for a discharge… I’m sort of making these numbers up on my reimbursements in the past, but it’s obviously a lot more than $30. )
And it doesn’t always work out. Sometimes I cannot get to the floors, and I’ve had patients who were very annoyed that no one was looking over their admission, especially me. Or, I’ve needed to have the on-call go see the patient anyways, even though they can’t get reimbursed either, and look over the case as I would, just to make sure the care and communication is going well. And I’ve been asked to do the same.
However, with few exceptions, the direct effect of this six-month experiment NOT admitting our practice’s patients, is that I’m on the floors a few times a week for a few short visits every week, as opposed to every day all day for one solid week every three months.
What I do now, these few (usually) short visits, are what I would call high-quality doctor-patient time, because I’m not managing minutiae or details, and definitely not doing much paperwork (No admit notes! No discharge summaries!) I’m really for the most part trusting the inpatient team, who usually do know alot more about the up-to-date protocols, studies and recommendations, as well as all those inpatient nuances, than I do.
What I AM doing is showing my face, doing my best to explain and reassure, and making a connection that will last through to the other side of the admission. It’s more of a big-picture assessment, one event in the context of a long-term relationship.
The inpatient teams have liked this approach. They generally jump up and down when the primary care shows up to deal with the social issues, to talk with the family… I haven’t even had anyone cringe or push back when I ask for consideration for some test, or one more day in-house. So far, so good on that.
And the end result is, I find myself striding through the hallways of this huge place, or scooting through bustling nurses’ stations, or hunting someone down in the labrynthine E.D. a whole lot more than I used to, and LIKING IT. Because when you take the paperwork crap and minutiae and figuring out who to call for whatever stuff OUT of it, plus endless long days managing patients who aren’t yours, and get to the big picture social issues and post-discharge life stuff of your very own patients, it’s fun.
It’s why I feel just like a real doctor lately.